Cardiac Rehab Is Going Digital. What Needs to Happen Next.

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An American Heart Association science advisory published last month focuses on gaps in the development and implementation of digital cardiac rehabilitation interventions aimed at promoting health equity and improving patient outcomes.

Jessica Golbus, M.D., M.S.

Writing in the journal Circulation, lead author Jessica R. Golbus, M.D., M.S., and colleagues explained that despite its benefits among patients, cardiac rehabilitation as a whole remains underused. Golbus is a clinical instructor in the division of cardiovascular medicine at University of Michigan Health.

“Even for those patients who participate in cardiac rehabilitation, there is the potential to better support them in improving behaviors known to promote optimal cardiovascular health and in sustaining those behaviors over time. Digital technology has the potential to address many of the challenges of traditional center-based cardiac rehabilitation and to augment care delivery,” authors wrote.

They defined cardiac rehabilitation as a secondary prevention program for individuals with cardiovascular disease. Digital technology refers to care delivered via the internet, wearable devices and smart phone apps. It also encompasses computational methods like artificial intelligence.

Many digital technologies are currently used to help deliver cardiac rehabilitation, as an adjunct to in-person services or through other modalities.

However, according to Golbus and colleagues “the field has moved toward a patient-tailored hybrid model of delivery that offers patients a combination of synchronous/in-person (cardiac rehabilitation) and synchronous/ real-time (cardiac rehabilitation).”

Many digital interventions tend to focus on physical activity or exercise training and lack other components, such as smoking cessation or lipid or diabetes management, Golbus and colleagues explained. Studies on these technologies also typically include patients with coronary artery disease at low or moderate risk, while higher risk patient groups are excluded.

Researchers stress these gaps need to be addressed before the interventions are included in routine practice. Additional studies in this field could also include more older patients, women and underrepresented racial and ethnic groups.

Issues involving internet access and connectivity also need to be ironed out, so patients living in rural areas have equitable access to new digital interventions. Keeping patients’ mental and physical aptitude in mind is also important. For example, patients with frailty may not have the dexterity needed to operate certain technologies.

The advisory highlights additional gaps when it comes to development and implementation of the interventions. Instead of focusing on specific technologies, which can make research findings from unusable when that technology changes, Golbus and colleagues advocate for “a more pragmatic approach to developing and evaluating digital interventions for [cardiac rehabilitation] that can be generalized broadly, including to existing videoconferencing platforms.”

This approach could focus instead on workflows and general behavioral principles, they wrote. Going forward, traditional practice patterns for cardiac rehabilitation will also require modification to better accommodate the technologies.

In addition, because randomized controlled trials are too slow to keep pace with the uptake of new digital tools, researchers suggest using alternative study designs, such micro-randomized trials or sequential multiple assignment randomized trials.

Overall, “there remains a need for normative digital data from diverse patient populations, including through expanded registries of digital biomarkers and clinical outcomes,” Golbus and colleagues wrote.

Once digital technologies become more integrated into clinical practice, the role of clinicians must be well-defined. According to authors, clinicians should be involved in patient assessment and technology selection.

Viewed through financial lens, cardiac rehabilitation has already proven to be cost effective, wrote Golbus and her colleagues, because it leads to fewer readmissions and improves quality of care. The integration of digital tools to enhance or replace center-based care may make the rehabilitation even more cost effective.

But in order for the interventions to reach their full potential, “several methodological gaps must first be addressed along the continuum from development to implementation with a focus throughout on digital health equity,” Golbus and colleagues concluded.